Basic Information
Provider Information | |||||||||
NPI: | 1508271776 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MEDINA CASTRO | ||||||||
FirstName: | ANNIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICENCIADA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MEDINA CASTRO | ||||||||
OtherFirstName: | ANNIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LICENCIADA | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | NUM 43 CALLE 9A BLOQ 23 | ||||||||
Address2: |   | ||||||||
City: | CAROLINA | ||||||||
State: | PR | ||||||||
PostalCode: | 009855414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7878770794 | ||||||||
FaxNumber: | 7872728796 | ||||||||
Practice Location | |||||||||
Address1: | COND CENTRO PLZ | ||||||||
Address2: |   | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 009092110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7874802783 | ||||||||
FaxNumber: | 7872748796 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2014 | ||||||||
LastUpdateDate: | 06/26/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | 938 | PR | Y |   | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
No ID Information.